Registered Nurse (RN) – Care Management | Chronic Care & Transitional Care
Clarkston Internal Medicine is a physician-owned primary care practice committed to delivering high-quality, patient-centered care in a supportive and collaborative environment. We are seeking a compassionate Registered Nurse (RN) to provide Chronic Care Management (CCM) and Transitional Care Management (TCM) services for our patient population.
This position is ideal for an experienced RN who enjoys care coordination, chronic disease management, patient education, and building long-term relationships with patients. You'll work independently while collaborating closely with physicians and clinical staff to improve patient outcomes, reduce hospital readmissions, and help patients successfully manage their health.
Unlike large health systems, our private practice offers the opportunity to truly know your patients, develop meaningful relationships, and make a lasting impact while maintaining a healthy work-life balance.
Responsibilities
- Manage a panel of patients enrolled in Chronic Care Management (CCM) and Transitional Care Management (TCM)
- Conduct post-discharge follow-up calls to reduce hospital readmissions
- Coordinate care with primary care providers, specialists, hospitals, home health agencies, and community organizations
- Develop individualized care plans and monitor patient progress
- Provide patient education on chronic disease management, medications, preventive care, and healthy lifestyle changes
- Perform medication reconciliation following hospital discharge
- Identify barriers to care and connect patients with community and social resources
- Assist patients with referrals, insurance questions, transportation, financial assistance, and other support services
- Promote preventive care and patient engagement through regular telephone outreach
- Document patient encounters accurately in the electronic medical record (EMR)
- Collaborate with physicians to improve quality measures, patient satisfaction, and value-based care initiatives
Qualifications
- Active Michigan Registered Nurse (RN) license
- Minimum of two years of nursing experience in primary care, care management, case management, ambulatory care, population health, or chronic disease management preferred
- Strong communication, assessment, and critical thinking skills
- Ability to work independently while effectively managing a patient caseload
- Experience with electronic medical records (EMR); Epic experience is a plus
- Passion for patient advocacy, education, and care coordination
Why You'll Love Working Here
- Physician-owned private practice with a supportive team culture
- Independent workflow with provider support when needed
- Opportunity to build meaningful, long-term patient relationships
- Monday-Friday schedule with no evenings, weekends, or major holidays
- Competitive salary and comprehensive benefits
- Stable, growing practice focused on quality care—not patient volume
- Collaborative environment where your expertise and clinical judgment are valued
Pay: From $75,000.00 per year
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Flexible schedule
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
